CT-guided versus bronchoscopic localization of small pulmonary nodules: a narrative review

Introduction

Background

Lung cancer is a leading cause of cancer death worldwide, ranking first among men and second among women (1,2). Surgical resection is the cornerstone of curative treatment for early-stage lung cancer, particularly with the growing adoption of minimally invasive techniques like video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) (3). These approaches offer improved recovery times and reduced postoperative complications compared to traditional open surgeries (3). However, their success hinges on the ability to precisely localize lesions, particularly for small or deeply situated nodules (4,5).

Rationale and knowledge gap

With the increased use of computed tomography (CT) scans, small lung nodules are detected more frequently (6,7). These nodules can be difficult to locate during surgery due to their size and the lung’s deformability, necessitating preoperative or intraoperative marking for accurate identification and resection (8-10). Localizing these lesions intraoperatively is challenging because they are often non-palpable, subsolid, or deep to the pleural surface; lung collapse and ventilation changes further distort spatial relationships. In recent years, the importance of limited surgery has been increasing, as evidenced by the results of the JCOG0802 and JCOG0804 trials. This has further emphasized the need for accurate localization of non-palpable lesions within the lung (11,12). Marking techniques help ensure precise surgical resection, which is crucial for both diagnostic and therapeutic purposes, especially in cases of early-stage lung cancer where sublobar resections are considered (9,13). Methods such as CT-guided methylene blue/collagen marking and indocyanine green (ICG)/lipiodol marking are used to localize nodules effectively before surgery, offering high efficacy and safety (8,13). Techniques like electromagnetic navigation bronchoscopy (ENB) allow for safe and effective localization of nodules, reducing the need for more invasive procedures like thoracotomy (10,14,15). In parallel, bronchoscopy-guided (BF-guided) localization has evolved with virtual bronchoscopy, electromagnetic navigation, and, more recently, robotic-assisted bronchoscopy, enabling more precise access to peripheral airways (16-18). Newer methods, including radiofrequency identification (RFID) systems, are being explored to improve the accuracy and ease of nodule localization (19). While lung nodule marking is a valuable tool in thoracic surgery, it is not without its drawbacks. Potential complications include pleural injury, pneumothorax, and variability in detection accuracy. Additionally, the complexity of some marking techniques can lead to procedural challenges (8,9,15,20,21).

Objective

This review aims to compare the clinical outcomes of CT-guided and BF-guided localization methods for small pulmonary nodules. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-11/rc).

Methods

Literature search, study selection, data extraction, and outcome definitions

We performed a literature search using the PubMed and Scopus databases. The PubMed search included terms related to lung surgery, pulmonary nodules, localization or marking, and specific techniques such as CT-guided methods (e.g., hook wire, microcoil, lipiodol, methylene blue) and bronchoscopic methods [e.g., virtual-assisted lung mapping (VAL-MAP), RFID, electromagnetic navigation]. The Scopus search used combinations of TITLE and abstract and keywords (ABS-KEY) terms covering pulmonary nodules, preoperative localization/marking, CT-guided techniques, bronchoscopic approaches, and advanced localization tools. Detailed search strategies are provided in Table S1 (PubMed) and Table S2 (Scopus).

After removal of duplicates, titles and abstracts were screened, and potentially eligible studies were further assessed by full-text review. Studies were excluded if they were animal experiments, case reports, lacked sufficient data, or were not relevant to the review theme. Ultimately, 51 studies met the inclusion criteria and were incorporated into the present analysis. The study selection process is illustrated in the flow diagram (Figure 1).

Figure 1 Flow diagram of study selection. Records were identified from PubMed and Scopus for studies published between January 2010 and December 2024. CT, computed tomography.

To facilitate concise presentation in the main text, we pre-specified a subset of representative studies to be tabulated while providing the full dataset in table available at https://cdn.amegroups.cn/static/public/vats-25-11-1.xlsx (CT-guided), and table available at https://cdn.amegroups.cn/static/public/vats-25-11-2.xlsx (BF-guided). The representative set was chosen a priori to (I) cover the major techniques (CT: hook wire, microcoil, dye excluding lipiodol, lipiodol, radiopaque/radioactive; bronchoscopy: VAL-MAP, navigation-assisted dye, RFID); (II) prioritize larger sample sizes and recent publications (approximately 2,018 onward); (III) prefer complete reporting of success and at least one safety endpoint (e.g., pneumothorax or hemorrhage); and (IV) avoid overlapping cohorts where possible. This selection was used only for display in the main-text table; all quantitative summaries in the manuscript (medians, ranges) were calculated from all included studies reporting each outcome and were not limited to the representative set.

We prepared a qualitative summary table to complement the narrative synthesis and the supplementary numeric tables. Before analysis, we prespecified five outcome domains to be summarized qualitatively: marking success, overall complication rate, pneumothorax, air embolism, and dislodgement or dye fading/diffusion (the last domain recorded as either device dislodgement for device-anchored methods or dye fading/diffusion for dye-based methods, whichever was reported). To ensure transparency and comparability, we applied simple label thresholds defined a priori: for success, “very high” indicated a median ≥95% across studies reporting the outcome and “high” indicated a median 90–<95%; for overall complications, “higher” indicated a median ≥10% and “lower” a median <10%; for pneumothorax, “very low” indicated a median 0–3%, “low” >3–<10%, and “higher” ≥10%; for air embolism, “rare” denoted ≤0.5% with sporadic occurrence and “not reported” denoted no events across the included series with available data; for dislodgement/fading, “very low” indicated a median of 0% with an upper range ≤5%, whereas “low-moderate” indicated a median >0% or an upper range >5%. These qualitative labels were anchored to the study-level medians and ranges we calculated from all included studies reporting each outcome (i.e., not restricted to the representative set).

Marking success was defined as placement of the intended marker at the planned site with intra-operative detectability sufficient to proceed with the planned resection without rescue localization (e.g., visible pleural dye, fluoroscopic cue for coil/lipiodol, or RFID signal). Complications during marking were abstracted as binary outcomes (event present/absent) from marker placement to the start of surgery. Because severity grading was inconsistent across studies, we did not perform grade-based analyses and report occurrence rates only.

Overview and classification of marking methods

Marking methods are fundamental to reliable preoperative localization for minimally invasive lung resection. In this revision, we synthesized 35 CT-guided and 16 BF-guided series. Across techniques, marking success was uniformly high, whereas the safety profile differed substantially between transthoracic and endobronchial approaches. Per-study details are provided in the table available at https://cdn.amegroups.cn/static/public/vats-25-11-1.xlsx (CT-guided) and the table available at https://cdn.amegroups.cn/static/public/vats-25-11-2.xlsx (BF-guided), and representative studies are summarized in Table 1 (CT-guided) (22-29) and Table 2 (BF-guided) (30-37). Following these pre-specified display criteria, we highlighted eight studies per approach to illustrate contemporary practice; these tables are descriptive displays, whereas pooled medians and ranges reported in sections “Overview and classification of marking methods” and “Qualitative summary of outcomes and comparison of techniques” derive from all eligible studies (see tables available at https://cdn.amegroups.cn/static/public/vats-25-11-1.xlsx, https://cdn.amegroups.cn/static/public/vats-25-11-2.xlsx for the complete study list). Technique-specific details are summarized as follows.

CT-guided marking

CT-guided localization encompassed hook wires, microcoils, dye injections excluding lipiodol (e.g., indigo carmine, ICG, methylene blue), and lipiodol as a distinct oil-based contrast marker, as well as other radiopaque/radioactive markers. Among studies reporting success, overall marking success was very high [median 98.4% (range, 83.8–100.0%); n=32]. Technique-specific medians were uniformly high: hook-wire and microcoil series frequently exceeded 99%, dye (non-lipiodol) series approached 100%, and lipiodol likewise achieved near-perfect success [lipiodol median 99.95%, range 99.9–100.0%, n=2; e.g., (22,28,38)]. Complication burdens reflected the transthoracic nature of the procedures. Overall marking-related complications ranged 0.0–91.2% (median 25.7%, n=33). Pneumothorax was the dominant event (range, 0.0–57.1%, median 16.3%, n=32), with higher rates in device-anchored approaches and variable rates in contrast-based methods; in lipiodol series specifically, pneumothorax ranged 6.6–57.1% (median 31.85%, n=2), whereas dye (non-lipiodol) series showed 0.0–48.0% (median 9.45%, n=4). Hemorrhage/hematoma varied widely (range, 0.0–85.0%, median 11.4%, n=20). Marker dislodgement was less frequently reported but clinically relevant (0.0–33.3%, median 2.7%, n=25). Air embolism, although rare, was observed only in CT-guided series in this dataset, with reported incidences up to 0.5% [e.g., (39-41)]. Radiopaque/radioactive series reported high technical success as well (29). Anesthetic practice varied across centers, with local anesthesia most commonly reported (16/35, 45.7%) and general anesthesia in 11/35 (31.4%), whereas a minority reported both or did not specify.

BF-guided marking

BF-guided techniques included VAL-MAP, navigation-assisted dye injections, and RFID. Among studies reporting success, overall marking success was very high [median 96.2% (range, 86.7–100.0%); n=16]. By sub-technique, median success was approximately 95% for VAL-MAP, 94% for navigation-assisted dye series, and ~98% for RFID. Larger and more contemporary cohorts underscore the reproducibility of VAL-MAP and navigation-assisted dye localization (30,31,34,35,42,43), while RFID demonstrates reliable signal-guided localization in smaller series (37). To illustrate resection planning, Figure 2 contrasts peripheral-side surface marking with central-side RFID placement; the latter enables signal-guided targeting from the deep aspect of the lesion and helps secure an adequate parenchymal (deep) margin (Figure 2).

Figure 2 Marking at the peripheral or central side of the lesion. (A) Peripheral-side marking—commonly used in dye-based or percutaneous techniques—may not always ensure an adequate deep margin. (B) Central-side marking with RFID enables signal-guided targeting from the deep aspect and helps secure a sufficient parenchymal margin. M, marking site; Margin, resection margin between marking site and tumor; RFID, radiofrequency identification.

Safety outcomes favored the bronchoscopic approach. The overall marking-related complication rate ranged 0.0–14.3% with a median of 1.8% (n=14). Pneumothorax was uncommon (0.0–6.6%, median 0.0%, n=12) and was frequently absent across consecutive series of VAL-MAP and navigation-assisted dye marking (30,31,42). Hemorrhage/hematoma and marker dislodgement were rarely reported and, where available, were 0% (n=3 and n=4, respectively). Air embolism was not reported in the bronchoscopic series with available data (n=16).

Anesthesia selection reflected procedural logistics. In this dataset, local anesthesia was reported in 8/16 studies (50.0%), general anesthesia in 7/16 (43.8%), and anesthesia status was not reported in 1/16 (6.2%). Programs commonly choose local anesthesia with mild sedation for flexible scheduling, whereas general anesthesia is used when integrating navigation or coordinating with other intraoperative steps (30,31,34,37).

Qualitative summary of outcomes and comparison of techniques

To complement the narrative synthesis and the supplementary numeric tables, we present a qualitative summary table (Table 3) based on a priori label thresholds defined in the Methods. In brief, both approaches achieved very high technical success; however, bronchoscopic marking consistently showed a lower overall complication burden. Pneumothorax was uncommon to absent in most bronchoscopic cohorts, and air embolism was not reported in those series (n=3). Dislodgement or dye fading was rarely reported in bronchoscopic studies and was low to moderate in CT-guided reports. Full study-level data are provided in the table available at https://cdn.amegroups.cn/static/public/vats-25-11-1.xlsx and the table available at https://cdn.amegroups.cn/static/public/vats-25-11-2.xlsx.

Both CT- and BF-guided strategies achieved consistently very high success [CT: median 98.4% (range, 83.8–100.0%), n=32; bronchoscopy: median 96.2% (range, 86.7–100.0%), n=16]. In contrast, safety outcomes clearly favored bronchoscopic approaches. The overall complication rate was markedly lower with bronchoscopy [median 1.8% (range, 0.0–14.3%), n=14] than with CT guidance [median 25.7% (range, 0.0–91.2%), n=33]. Pneumothorax—the most frequent and consequential event in localization workflows—was substantially attenuated in bronchoscopic series (median 0.0%, up to 6.6%, n=12) compared with CT-guided reports (median 16.3%, up to 57.1%, n=32). Dislodgement and hemorrhage were infrequently reported in bronchoscopic cohorts (available series reporting 0% for both, n≤2 and n=1, respectively), whereas CT-guided cohorts exhibited medians of 2.7% (0.0–33.3%, n=25) and 11.4% (0.0–85.0%, n=20). Air embolism—though rare—appeared only in CT-guided series within this dataset (up to 0.5%, median 0.0%, n=15), with no events reported in bronchoscopic studies (n=16) [e.g., (39-41)]. Taken together, these findings indicate that while both paradigms provide reliable localization, BF-guided marking confers a more favorable safety profile, plausibly attributable to the absence of transthoracic puncture. Patterns of anesthesia use differed by workflow: CT-guided marking leaned toward local anesthesia at the study level, whereas BF-guided marking was divided between local with sedation and general anesthesia, often dictated by navigation modality and perioperative scheduling.

Discussion

Key findings

Across 35 CT-guided and 16 BF-guided series, both approaches achieved very high technical success, whereas the safety profile consistently favored bronchoscopy. In CT-guided cohorts, pneumothorax constituted the dominant complication and air embolism, although rare, was observed only with percutaneous techniques [e.g., (39-41)]. By contrast, BF-guided series frequently reported no pneumothorax and no air embolism. These differences persisted even though localization success remained near-perfect in microcoil series (41,44,45) and in contemporary bronchoscopic cohorts including RFID (37).

CT versus bronchoscopy: advantages, drawbacks, and candidacy in practice

CT-guided techniques (hook wire, microcoil, non-lipiodol dyes, lipiodol as an oil-based radiopaque agent, and radiopaque/radioactive markers) provide immediate intraoperative cues—either a physical lead (hook wire), fluoroscopic landmarks (microcoil, lipiodol, radiopaque/radioactive seeds), or direct visualization [blue dyes/near-infrared (NIR) for ICG]. Their drawbacks stem from transthoracic puncture: pneumothorax and hemorrhage are more frequent, and air embolism, while uncommon, is a recognized risk specific to the percutaneous route [e.g., (39-41)]. Hook-wire dislodgement during transfer or lung deflation is reported in multiple series (22,46,47). Dye-based strategies introduce time-dependent visibility—fading or diffusion can occur if the interval to surgery is prolonged (28). Beyond the well-recognized time dependence of dye visibility, intraoperative observations suggest that some events labeled as “fading/diffusion” likely reflect technical and optical factors. First, if the injectate is deposited deeper than the subpleural layer (e.g., within the interstitium or along septa), the mark may not show through the pleura even without true washout. Second, pleural surface discoloration (e.g., anthracotic pigmentation or scarring) can mask blue dyes and reduce visual contrast; for ICG, intervening parenchymal thickness and strong surface pigmentation may attenuate NIR signal. These mechanisms plausibly contribute to the observed variability in dye-based visibility across studies and underscore the importance of controlling injection depth/volume and planning subpleural, multi-spot placements (28). Treating lipiodol as distinct from water-soluble dyes is clinically relevant: it affords durable fluoroscopic visibility and strong retention for deeper nodules (22,38), yet its pneumothorax burden appears relatively higher in our dataset and injection must avoid intravascular tracking. Radiopaque/radioactive markers also achieved high success in smaller series (29).

Access considerations further shape candidacy for CT-guided marking. A safe straight needle path may be limited by bony structures (e.g., ribs or scapula) and by target position (apex, fissures, near diaphragm), necessitating longer or oblique traverses and potentially increasing procedure complexity—points emphasized in recent overviews (48).

BF-guided techniques (VAL-MAP, navigation-assisted dye injection, and RFID) avoid traversing the chest wall and therefore attenuate pneumothorax risk. Feasibility depends primarily on airway reachability and navigation accuracy (e.g., the presence of a bronchus sign). In contemporary series, VAL-MAP and navigation-assisted dye have shown reproducible localization with low complication rates [e.g., (30,31,34,35,42,43)]. As with CT-guided dye injection, however, non-visualization can occur and is not solely time-dependent: misdirected spray or deeper-than-subpleural deposition may fail to show through the pleura, and pleural surface discoloration (e.g., anthracosis or scarring) or pleural adhesions can reduce contrast or limit surface spread of dye.

RFID adds a signal-based, depth-aware marker that permits intraoperative re-identification and can support deep margin control (37). Unlike dye, RFID is not susceptible to fading or diffusion; nonetheless, its performance remains contingent on airway reachability, and rare failures may arise from malposition/migration in unfavorable anatomy. These mechanistic and operational contrasts align with prior overviews of BF-guided localization while complementing our approach-level quantitative comparison.

In practice, approach selection should integrate (I) lesion depth and pleural distance; (II) the interval to resection (especially for dyes); (III) available intraoperative visualization (fluoroscopy, NIR); (IV) anesthesia workflow [local vs. general; stand-alone marking vs. hybrid-operating room (hybrid-OR)]; and (V) airway anatomy (bronchus sign, airway caliber). Our technique-level qualitative summary in Table 4 consolidates these operational determinants without blurring the CT-versus-bronchoscopy structure.

Technique-level practical comparison and overview of less familiar modalities

To complement the approach-level analysis above, Table 4 summarizes practical attributes across individual techniques (workflow steps, equipment/personnel, anesthesia, intra-operative visualization, timing/logistics, and typical failure modes). For bronchoscopic approaches that may be less familiar, VAL-MAP deposits multiple subpleural dye spots planned on virtual bronchoscopy to create a surface “map” that guides wedge/segmental lines (30,31,42); navigation-assisted dye (ENB-dye) uses electromagnetic navigation to deliver a small dye bolus near the lesion and relies on thoracoscopic visualization (34,35,43); and RFID bronchoscopically deploys a small tag proximal to the target, enabling repeated signal-based localization and deep-margin control (37). As depicted in Figure 2, RFID can be positioned on the central side of the lesion rather than only on the pleural/peripheral side. This depth-aware placement supports stapling from deep to superficial planes and reduces the risk of an insufficient deep margin compared with purely peripheral surface dye marks (Figure 2). On the CT-guided side, hook wire offers a physical lead, microcoil and lipiodol provide fluoroscopic landmarks (the latter with durable oil-based retention), and water-soluble dyes afford direct visual cues; all percutaneous methods share pneumothorax/hemorrhage risks inherent to chest-wall traversal [e.g., (22,28,38,41,44-47)]. Readers are referred to Table 4 for side-by-side operational details; pooled medians/ranges remain as synthesized in Results and summarized in Table 3. To complement the narrative comparison, Figure 3 provides a concise visual schema of all seven techniques, aligned with Table 4 to highlight workflow steps, required equipment/personnel, anesthesia/logistics, and the nature of intraoperative guidance (physical lead, fluoroscopic cue, visual dye, or RFID signal).

Figure 3 Technique schematics (not to scale). In all panels, the purple nodule indicates the target tumor. CT-guided: (A) Hook wire (barbed lead traversing the chest wall); (B) microcoil (pleural-bridging coil; fluoroscopic cue); (C) dye (non-lipiodol) single/multi-spot subpleural deposit (visual cue); (D) lipiodol (oil-based radiopaque bleb; fluoroscopic cue). BF-guided: (E) VAL-MAP (multi-spot surface mapping for orientation); (F) navigation-assisted dye (target-adjacent spot via ENB or virtual bronchoscopy); (G) RFID (proximal “central-side” tag enabling signal-guided, depth-aware stapling). BF-guided, bronchoscopy-guided; CT, computed tomography; ENB, electromagnetic navigation bronchoscopy; RFID, radiofrequency identification; VAL-MAP, virtual-assisted lung mapping.

Key contrasts highlighted by Table 4

Compared with CT-guided techniques, BF-guided methods avoid chest-wall traversal and therefore attenuate pneumothorax risk while enabling same-room marking-to-resection workflows when navigation is integrated (30,31,42). Dye-based strategies—whether CT- or BF-guided—are time- and depth-dependent: marks deposited deeper than the subpleural layer may not appear on the pleural surface, surface discoloration (anthracosis/scar) can mask blue dyes, and NIR ICG can be attenuated by intervening parenchyma; these effects are amplified when the interval to surgery is prolonged (28). Lipiodol should be considered distinct from water-soluble dyes—its fluoroscopic visibility is durable and helpful for deep nodules, yet percutaneous injection in our dataset carried a relatively higher pneumothorax burden (22,38). RFID avoids fading/diffusion and allows repeated intra-operative re-identification, but success remains contingent on bronchial reachability and device availability (37).

Determinants of success and complication profiles across techniques

Based on our dataset, marking success for both CT-guided and bronchoscopic techniques clusters within 85–100%. Residual variability—seen mainly with hook wires or microcoils—reflects case-mix and workflow/device factors (deep or fissure-adjacent targets, emphysema, anchoring depth, patient repositioning). Hook wires persist because they are simple, fast, widely available, and provide immediate tactile/visual cues; in contemporary cohorts, success commonly approaches ~100%, consistent with our pooled medians [e.g., (22,46,47)]. Differences in complication profiles align with device mechanics: pneumothorax is higher with hook wires because a stable pleural puncture and externalized tether must be maintained during transfer/deflation, whereas microcoils—although less prone to tether-related issues—can shear small vessels during parenchymal/pleural traversal, explaining higher bleeding ranges in some coil series (41,44,45). For dye-based methods, reliability depends on injection depth (subpleural vs. interstitial), distance to pleura, bolus volume/concentration, and dye chemistry (water-soluble blue dyes vs. ICG with NIR detection); marks placed too deep may be invisible despite retention, very superficial deposits may spread along pleura, and longer intervals to resection increase apparent “fading/diffusion” (28). These mechanisms, together with the modality-specific examples above [lipiodol: (22,38); RFID: (37)], account for the observed spread in success and the distinct complication patterns across techniques.

Comparison with prior reviews and contribution of the present study

Prior syntheses are informative yet largely method-specific or narrative. Imperatori 2021 narratively reviews perioperative identification techniques, underscoring that evidence is primarily case series and that complications (e.g., pneumothorax/bleeding with hook wires; rare air embolism) are technique-linked, but without a unified approach-level comparison (49). Tang 2022 surveys intraoperative identification across CT-guided and BF-guided modalities and highlights dye diffusion constraints and hybrid-OR workflows, again as a narrative overview (50). Gkikas 2022 focuses exclusively on ICG, reporting high success with complications largely tied to CT-guided insertion events, but by scope cannot adjudicate non-ICG methods or the broader CT-versus-bronchoscopy contrast (51). Wang 2024 provides a comprehensive review and explicitly notes CT access limitations at the apex, fissures, diaphragm, or under the scapula, but remains descriptive rather than comparative at the approach level (48).

Against this backdrop, the present work contributes five elements: a direct CT-versus-bronchoscopy comparison using a shared set of outcomes; pooled medians and ranges where feasible (e.g., pneumothorax, dislodgement, hemorrhage, air embolism); integration of RFID within the bronchoscopic arm (37); a qualitative label table (Table 3) that complements numeric synthesis; and technique-level operational context in Table 4. Collectively, these enable a pragmatic, approach-level appraisal that the prior reviews did not attempt.

Future directions

Because many targets are ground-glass nodules with indolent biology, the risk–benefit calculus favors strategies that minimize procedure-related harm. Avoiding chest-wall puncture inherently addresses the complications of greatest concern—pneumothorax and air embolism—which are mechanistically linked to percutaneous access and highlighted in prior appraisals of CT-guided techniques.

Nevertheless, CT-guided localization retains pragmatic advantages in many settings—lower up-front cost, broad availability and installed base, and lean staffing—so it remains widely implemented. Future device innovation that preserves these practical strengths while eliminating percutaneous failure modes (in particular pneumothorax and the possibility of air embolism) would further improve the risk–benefit profile of CT-guided workflows.

Within BF-guided methods, RFID appears particularly promising in our synthesis: series report high success with favorable safety and intraoperative re-identification enabling deep-margin control and repeated confirmation (37). Barriers—cost, equipment, and training—should be addressed via multicenter validation, standardized outcome definitions (explicitly distinguishing device dislodgement from dye fading/diffusion), and cost-effectiveness analyses. Navigation enhancements (e.g., cone-beam computed tomography-assisted registration) and hybrid-OR workflows may further de-risk localization while preserving efficiency.

In light of the approach-level safety profile and the need for reliable intraoperative re-identification, our center has integrated bronchoscopic RFID localization for selected cases in which deep-margin control and repeated confirmation are operational priorities. This reflects local logistics and equipment availability and should not be interpreted as evidence of superiority over other techniques; formal prospective evaluation is warranted and should be pursued.

Limitations

Our synthesis is limited by the observational nature of most included studies, heterogeneous reporting (especially for dislodgement vs dye fading and minor complications), and variable perioperative timing that affects dye visibility. Technique choice is center- and device-dependent, introducing selection and learning-curve biases. While we prespecified qualitative thresholds and separated technique-level detail in Table 4, residual confounding cannot be excluded.

Conclusions

Both CT- and BF-guided localization achieve very high technical success in contemporary series. Complication profiles differ by access route: pneumothorax is generally more frequent and air embolism has been reported only with percutaneous CT guidance, whereas bronchoscopic approaches depend on airway reachability and navigation resources. Technique selection should be individualized to lesion characteristics (size, depth, pleural distance, bronchus sign), intraoperative workflow (available imaging and anesthesia), and local expertise/equipment. Emerging options such as RFID are promising but require multicenter validation and standardized endpoints before firm comparative recommendations can be made.

Acknowledgments

This work would not have been possible without the dedication and support of the clinical staff. We extend our heartfelt gratitude to all ward staff and department members for their invaluable contributions.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-11/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-11/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-11/coif). F.T. reports grants from Boehringer Ingelheim Japan, Ono pharmaceutical, Taiho pharmaceutical, Illy Lilly Japan and Chugai Pharmaceutical; consulting fees from AstraZeneca, Chugai Pharmaceutical and Ono Pharmaceutical; payments for speaker’s bureau from MSD, Bristol-Meyers Squibb, Boehringer Ingelheim Japan, Ono Pharmaceutical, Johnson & Johnson, Covidien Japan, Taiho pharmaceutical, Illy Lilly Japan, AstraZeneca, Chugai Pharmaceutical, Kyowa-Kirin, Takeda Pharmaceutical, Pfizer, Olympus, Stryker and Intuitive Japan. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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